Friday, February 14, 2014

A Psychological Vision of Life Beyond the Disease Model

It’s easy to become jaded about academic conferences. You
fly at enormous expense across many time-zones to enjoy the dubious delights of
corporate tourism – natural Edens questionably enhanced by international
capitalism with a thin veneer of local colour. To justify the tawdry tourism,
we see poorly-attended seminars presenting work that hasn’t (yet) managed to
squeeze past peer-reviewers and ‘networking’ opportunities that seem more to do
with alcohol and reinforcement than the challenging of received wisdom.

Having got all that off my chest, I am delighted to have
attended the American Psychological Association’s Annual Convention in Hawaii
in August. Lucy Johnstone, Richard Pemberton and I joined colleagues from
Division 32, the Society for Humanistic Psychology, to hold a seminar and a
workshop. We were, of course, inspired by our international collective effort
to discuss the implications of, and alternatives to, traditional psychiatric
diagnosis and the “disease-model” dominant philosophy of psychiatry and mental
health care. What we experienced was a near-perfect example of what academic
and professional psychology conferences can achieve–if we take forward the
ideas we discussed.

Colleagues from Division 32 and from the British
Psychological Society’s (BPS) Division of Clinical Psychology have, of course,
been collaborating for about two years to develop a forum for critical debate
over the development of DSM-5. We see ourselves to have been successful – it is
genuinely difficult to find media commentaries of DSM-5 that do not include
some synonym of “controversial”. Hawaii offered a venue for us to come
together, to share perspectives on the current debate over diagnosis and,
through the benefits of face-to-face meeting, to discuss the practice of clinical
psychology in the emerging immediate future – a world without the disease model
of psychiatry, in a world which helps people realize their potential and
develop their psychological well-being.

Our symposium on Saturday 3rd August perfectly summarized
many of our scientific and professional concerns about DSM-5, diagnosis and the
disease-model. Joshua Clegg opened the symposium by discussing the procedures
through which the American Psychiatric Association cultivated the development
of DSM-5 and the involvement of psychologists in that process. It was
important, I think, that Joshua separated the discussion of ideas from a
conflict between professions. Joshua reminded us of how the task force
developing DSM-5 were motivated by noble aspirations, despite the apparent
links of many participants to commercial interests. And Joshua reminded us that
both psychologists and psychiatrists are active on all sides of the debate.
Brent Robbins discussed the role of both the BPS Division of Clinical
Psychology and Division 32 in responding to the DSM-5 task force in developing
an ‘Open Letter‘ petition signed by thousands of individuals and institutions
expressing some of our concerns, and in developing an international coalition
of mental healthcare professionals who continue the debate and discussion on
the internet at DxSummit.org and at upcoming conferences and international
working groups.

Nancy McWilliams, Philip Cushman, and Joan Chrisler gave
different but powerful accounts of how traditional psychiatric diagnosis fails
to meet the needs of individuals in distress, of clinicians and of society.
Nancy deconstructed the notion of “personality disorder” and explored how value
judgments about what are essentially normative rules for appropriate behavior
are transformed into criteria for the diagnosis of “psychiatric illnesses”,
with all the implications for assumptions about “aetiology” and “treatment”
that inappropriately follow. Philip returned to the origins of the DSM
diagnostic system – in addressing the traumatic effects of conflict. In a
masterful speech, Philip illustrated how labeling our natural and normal
reactions to unsustainable trauma as “symptoms of mental illness” emerged as a
cynically predictable response to industrialized warfare, but obscures our necessary
human and humane, psychological and political, response to war. Joan referred
to the ways in which the politics of gender again transform stereotypes into
diagnostic criteria and demonstrated this with some very clever research
findings.

And I spoke too. Much of what I said was unnecessary – the
earlier speakers addressed my agenda with much more eloquence than I could
muster. I spoke about things that I’ve said before. I suggested that
traditional psychiatric diagnosis, and its partner of the “disease-model”, are
unscientific, unhelpful and inhumane. I commented that DSM-5 is merely likely
to make a bad situation worse.

But what was particularly good about Hawaii, why it was
worthwhile attending a conference thousands of miles from home, was that we
discussed the future and shared plans. We didn’t conspire in the shadows – we
presented our ideas in public (and I’m writing about them now). In our
symposium, and in a subsequent workshop given by Richard Pemberton and Lucy
Johnston, we talked about more than mere criticism of DSM-5. It was, I believe,
right to organize critical debate internationally in response to the
publication of DSM-5. But we can do more. We can look forward to a world in
which psychologists and colleagues help people to recover from psychological
distress, maximize their well-being and fulfill their potential in life without
recourse to medicalised diagnosis, the “disease-model” of psychiatry and, of
course, without assuming that life-time medication is the only salvation.

We don’t need to invent a “new alternative”. We need to stop
doing the wrong things, and we need to use those established approaches that
offer an existing, proven and effective alternative. I am proud, for instance,
of my chosen profession as a clinical psychologist. As Richard and Lucy
illustrated presenting the BPS’s Division of Clinical Psychology’s work on
formulation, accurate, objective and operationally useful definitions of
psychological phenomena (of all kinds) has always been the basis of our science
and our profession. We don’t need to diagnose, but we don’t need to wait for a
new alternative – we have the alternative already. For decades, psychologists
have resolutely and systematically developed scientifically valid ways to
define, observe and if appropriate to quantify psychological phenomena. We have
no need to “diagnose” – artificially and invalidly to group these phenomena and
associate them with putative “illnesses”. Yes, we should criticize inanities
such as DSM-5. But we shouldn’t fall into the trap that we have to wait for new
technologies to be invented before we have an alternative. We have – and we
practice every day – the alternative now.

So, Hawaii may well have been both useful and a little bit
of a turning point. We shared our views, and we thought carefully and
critically about the issues before us. We celebrated our success in promoting
wise and humane – albeit critical – debate. But also, by meeting and sharing
conversation, we recognized the transition from a campaign to point out the
inadequacies of diagnosis and the “disease-model”, to a more positive promotion
of the possibility of a psychological vision of life beyond the disease model.

This concept of "stop doing the wrong things..." should be embraced and promoted all over the psychiatric and medical community. Every doctor should be immediately identifying within their own work what they are "doing wrong". Perhaps, it is easier to label a patient as being wrong versus the clinician as falling victim to "wrong" practices. Patients don't need doctors to define if they are normal, that's what teenagers are for. Patients need professionals who provide the right treatment and care.

Thank you for stating the obvious!

Thank you for being the type of professional who can bravely stand before your peers and patients and speak truth.